Provider Demographics
NPI:1013489616
Name:MENDEZ, JONATHAN ALLEN (LPC)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:ALLEN
Last Name:MENDEZ
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2607 VINEVILLE AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-0900
Mailing Address - Country:US
Mailing Address - Phone:478-305-9913
Mailing Address - Fax:
Practice Address - Street 1:2607 VINEVILLE AVE STE 107
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-0900
Practice Address - Country:US
Practice Address - Phone:478-305-9913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010577101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional